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A 4yo, 20kg patient presents to the ED with a 1 hour history of vomiting after eating a candy bar. While in the waiting room he has a syncopal event and is brought immediately back to room one. Initial vitals are T 37, HR 160, RR 20, BP 70/45. He is pale and diaphoretic with bilateral wheezing on auscultation. His abdomen is soft and non-tender. You note some facial swelling, a faint raised erythematous blanching rash on his trunk and cool extremities with capillary refill time of 4 seconds. What medication should be administered first?A.IV methylprednisoloneB.IM epinephrine 1:1000C.IM epinephrine 1:10,000D.IV ceftriaxone E. IV dopamine

ANSWER:B. This patient is exhibiting signs of anaphylaxis (GI symptoms, CNS dysfunction, hypotension, wheezing, facial swelling, hives). In this patient the GI symptoms preceded the skin findings (which may be absent in 20% of patients). Delay in the administration of epinephrine can lead to increased risk of death in anaphylaxis. Answer C is the wrong dose of epi – it is cardiac epi. Answer A should be given but only after epinephrine. D is not necessary unless the patient shows signs of infection and while E may be needed, IM epi should be given first.

PEARL:Do not delay administration of IM epinephrine in anaphylaxisDose: 0.01mg/kg of 1:1000

Sicherer et al. Self-injectable Epinephrine for First-Aid Management of Anaphylaxis Pediatrics 2007;119;638Anaphylaxis is a severe, potentially fatal systemic allergic reaction that is rapid in onset and may cause death. Epinephrine is the primary medical therapy, and it must be administered promptly. This clinical report focuses on practical issues concerning the administration of self-injectable epinephrine for first-aid treatmentof anaphylaxis in the community. The recommended epinephrine dose for anaphylaxis in children, based primarily on anecdotal evidence, is 0.01 mg/kg, up to 0.30 mg. Intramuscular injection of epinephrine into the lateral thigh (vastus lateralis) is the preferred route for therapy in first-aid treatment. Epinephrine autoinjectors are currently available in only 2 fixed doses: 0.15 and 0.30 mg. On the basis of current, albeit limited, data, it seems reasonable to recommend autoinjectors with 0.15 mg of epinephrine for otherwise healthy young children who weigh 10 to 25 kg (22–55 lb) and autoinjectors with 0.30 mg of epinephrine for those who weigh approximately 25 kg (55 lb) or more; however, specific clinical circumstances must be considered in these decisions. This report also describes several quandaries in regard to management, including the selection of dose, indications for prescribing an autoinjector, and decisions regarding when to inject epinephrine. Effective care for individuals at risk of anaphylaxis requires a comprehensive management approach involving families, allergic children, schools, camps, and other youth organizations. Risk reduction entails confirmation of the trigger, discussion of avoidance of the relevant allergen, a written individualized emergency anaphylaxis action plan, and education of supervising adults with regard to recognition and treatment of anaphylaxis.

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